Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Thursday, August 28, 2008

Back to first principles

Unfortunately, most of the comments I attract here are from people who basically agree with me, which is not all that much fun. I had a brief burst of creationists at one time -- now that was hot -- but other than that, the only recurring challenges come from libertarian perspectives. Glad to have them, who wants to preach to the choir all the time?

I once tried to capture the difference between liberalism and libertarianism in a nutshell with an aphorism to the effect that liberals believe society must establish liberty, while libertarians believe that liberty just happens. I believe the former, and I also believe that health and health care provide a felicitous occasion for the demonstration.

Libertarianism is founded largely on principles that liberals share, notably a high value placed on personal autonomy, but they part on considerations of reality. It should be obvious that the scope of our freedom depends on our resources, which include natural endowments (over which we have no control, for which we have no desert, and the fruits of which are inherently unjust, in my view, and be careful if you want to object to that, you may not like where it leads); the resources society bestows upon us by virtue of our birth, such as George W. Bush's political career and Cindy McCain's many mansions; and what comes to us by luck, be it the rain that nourishes one farmer's crop and the drought that destroys another's, or the disease that deprives one person of vigor and not the next. After all that, if you wish to argue that some of our power to enjoy our liberty comes from what we have earned by enterprise, you will have to notice that said enterprise is frequently unethical and rapacious. The most ruthless and unprincipled often -- I would say usually -- become the most powerful, and then what happens to the liberty of the rest of us?

A person who is wealthy, healthy and socially powerful obviously enjoys more liberty than one is is poor, sick and marginalized. But these conditions have little to do with desert.

Libertarians presume a fundamental right to use and enjoy one's property as one wishes. If pecuniary differences are not deserved, this is already suspect, but then it founders on an inescapable self-contradiction: what if you want to use your property to deprive me of my liberty? Fine, say the libertarians, we will pass the most limited set of laws necessary to restrict that sort of behavior: robbery, kidnapping, rape, will be illegal, but leave it at that.

But it is not only those extremes which are at issue. There is almost nothing you can do that does not affect the liberty of others. Your liberty and my liberty are always a problem of balancing. They must be negotiated. Liberty does not consist of you always getting your way, as libertarians often seem to think. After all, I can just turn that around.

Liberals and libertarians, therefore, tend to agree on the easy cases, where laws or institutions try to restrict behavior that has limited impact on others but is merely morally disapproved, such as private sexual or drug using behavior. They have major disagreements, however, on situations in which people interact willy nilly, notably the design of economic institutions. The libertarian position, as it turns out, depends on premises about the economic system which are simply false.

Consider the health care industry. This industry is unusual in many ways, though not so fundamentally unusual as many people seem to think. One unusual feature is that people's basic need for its output varies so hugely. Our daily caloric requirement varies somewhat depending on metabolism, age and body size, but within a fairly constrained range. But some people, in a given year, don't actually need any health care at all, while others might need hundreds of thousands of dollars worth to remain alive. Some people need to consume high levels their entire lives, others episodically or only toward the end, others need comparatively little for a lifetime.

What percentage of this variation is deserved or "just" may be argued. Some proportion of sickness may be attributed to irresponsibility, but it is certainly much less than half. And even people whose personal behavior may have contributed to their sickness aren't 100% responsible. For example, tobacco companies spent hundreds of billions of dollars promoting and marketing cigarettes, creating doubt about whether they were really dangerous, and creating a popular culture in which they were not only accepted, but symbols of sexiness and sophistication. Many people are in ill health because they were born into poverty, or breathed polluted air, or happened to catch an infectious disease, or were physically assaulted, or in a car crash, and so on. And, of course, our health just tends to get worse as we get older, which all of us hope to do.

Second, the maintenance of one person's health is not important only to that one person. People have dependents and loved ones who care what happens to them regardless of the degree to which their affliction may be "deserved." Their contribution to society as workers, parents, volunteers, neighbors, friends, etc. is affected by their state of health, so we may all be harmed by a less healthy population. People may carry infectious diseases. And, whether because of empathy or mere aesthetics, everyone's quality of life is compromised if there are a lot of sick, impoverished people sleeping in the doorways. In other words, there are externalities associated with our utilization of health care, whether determined by our choices or our resources. When people don't get enough, others suffer.

Third, health care is an expert service. I can determine my own preferences in many matters, from what foods to eat (assuming I have an adequate budget), to whether to spend my surplus on theater tickets or a sailboat, if I'm that lucky. But contrary to the (truly preposterous, in this case) arguments of libertarians, I don't consume health care because I feel like it, or enjoy it, or get intrinsic rewards from undergoing a mammogram or a colonoscopy. I consume health care because my doctor recommends it. If I have to pay more, I may well get less of it, but what I forego will be services that my physician would have recommended, since there are no others that I would even consider buying in the first place. (There are people who are exceptions, but they are eligible for a DSM-IV diagnosis.) Whether the physician is always right is another question, but that is not determined by the amount of money I have to pay.

Any argument about the proper way to structure the health care and health insurance systems must begin by acknowledging these underlying realities. Arguments for "consumer driven" or "free market" health care do not, and are therefore fundamentally invalid.